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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 134600626
Report Date: 05/22/2024
Date Signed: 05/22/2024 11:06:54 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/19/2022 and conducted by Evaluator Amy Rodgers
COMPLAINT CONTROL NUMBER: 08-AS-20220519111512
FACILITY NAME:SMOKETREEFACILITY NUMBER:
134600626
ADMINISTRATOR:ELIZABETH WAYCOTTFACILITY TYPE:
735
ADDRESS:1663 SMOKETREE DRIVETELEPHONE:
(760) 353-6203
CITY:EL CENTROSTATE: CAZIP CODE:
92243
CAPACITY:6CENSUS: 0DATE:
05/22/2024
UNANNOUNCEDTIME BEGAN:
10:46 AM
MET WITH:Direct Care Giver Shannon ArmstongTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff physically abused client.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Amy Rodgers, conducted an unannounced visit as a follow up for complaint investigationt, and delivered complaint findings. The LPA introduced herself and disclosed the purpose of the visit to Direct Care Giver Shannon Armstong.

Throughout the investigation, the Department secured records and conducted interviews with external and internal sources.

It was alleged staff physically abused a client that resulted in a eye that was red and irritated. On 05/19/2022, the Department received an SOC 341 of suspected adult abuse. It was reported Client # 1 (C1) had sustained an injury due to staff abuse. On 5/18/22, Police were called to a day program facility where C1 attends program. Police and an outside agency conducted interviews and C1 was allowed to continue to stay at facility.
(See LIC 9099C form for continuation of report.)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 08-AS-20220519111512
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: SMOKETREE
FACILITY NUMBER: 134600626
VISIT DATE: 05/22/2024
NARRATIVE
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 According to C1’s Physician Report C1, has a history of eye problems and has been taking several medication for the eye condition. Additional records as well as interviews revealed C1 has a history of fabrication. Interview with staff (S1 and S2) as well as outside source (OS1) confirmed that before and on the date of the incident C1 was suffering from eye problems.

A review of the police report verifies C1 did not have other visible or fresh injuries to her face or eyes and C1 did have slight redness to both her eyes. Interviews with staff, outside sources and client conducted indicate the alleged abuse never occurred and most likely was fabricated by C1.

Based on LPA's interviews, and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Licensee to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2